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4th INTERNATIONAL CONSENSUS SUMMIT FOR SLEEVE GASTRECTOMY IV: Sleeve as a Revisional Surgery Technichal Considerations in Performing Sleeve as a Revisional Surgery by PRATIBHA VEMULAPALLI, MD, FACS Bariatric Times. 2013;10(5 Suppl A):A16–A17 AUTHOR AFFILIATIONS: Dr. Vemulapalli is Director of Bariatric Surgery, Montefiore Medical Center, New York, New York. ADDRESS FOR CORRESPONDENCE: Pratibha Vemulapalli, MD, FACS, 3400 Bainbridge Ave, 4th Floor, Bronx, NY 10467; Phone: (718) 920-7277; E-mail: pratv@hotmail.com FUNDING AND DISCLOSURES: No funding was provided. The authors report no conflicts of interest relevant to the content of this article. KEY POINTS • LSG can be done in as either a one or two stage procedure. • Major complications are not necessarily higher. • 40 French bougie size may help decrese complications. L aparoscopic sleeve gastrectomy (LSG) has been shown to have effective short- and long-term weight loss as a primary procedure.1 However, LSG can be an effective revisional procedure,2 primarily as gastric band to sleeve or re-sleeve. A re-sleeve procedure can be done either as a revision of a primary LSG after radiographic or endoscopic evidence of regrowth of the cardia or part of a biliopancreatic diversion (BPD) when the patient requires more weight loss. When converting a band to a sleeve at my facility, we often perform the operation in one or two stages, depending on the patient. Prior to deciding whether to do the A16 operation in one or two stages, all patients undergo an upper gastrointestinal (GI) series and endoscopy. If both tests show no esophageal dilation, pouch dilation, or slippage then the patient can undergo a one-stage operation. If, on the other hand, there is dilation of the pouch or esophagus, the patient is carefully surveyed for Barrett's esophagus. The band is then removed and the patient is scheduled for LSG in 3 to 6 months after band removal. In my experience, when the abdomen is reentered, there is rarely any evidence that the band was ever there. The stomach where the capsule sat is pristine as is the stomach at the left crux. If sleeve conversion is attempted in the midst of a slippage, the stomach above the band is often thick, inflamed, and difficult to shape. The staple line is often not straight in these patients, and it can be torqued causing not only immediate postoperative problems such as leaks, but also long-term Bariatric Times • May 2013 • Supplement A dysphagia that is difficult to endoscopically dilate. Conversely, the patient may experience weight regain from an unintended "dog ear." Weight loss after band to LSG is durable. My colleagues and I have shown that even when converting a restrictive procedure (adjustable gastric banding) to another restrictive procedure (LSG), the weight loss is excellent.3 In our series of 15 band to LSG procedures, patients experienced 55-percent weight loss at 14 months postoperative.3 Additionally, we reported no major complications (e.g., leaks, pulmonary embolism, and mortality). AUTHOR'S TECHNICAL CONSIDERATIONS When approaching bariatric surgical revisions, several points must be considered. First, sharp dissection is important. Excessive usage of staples or electrocautery, especially when taking down the band capsule, can cause secondary unintended thermal